1. Local Anesthesia for Patients Pediatric Dr. William H. Lieberman D.D.S., M.B.A.

2. Brief Bio. Dr. William H. Lieberman D.D.S., M.B.A. Private pediatric practice in New Jersey Past-President American Society of Dentistry for Children MBA, Healthcare Coordinator Dental Continuing Education, Monmouth Medical Center Assistant Clinical Professor at New York University

3. 1975-2011Then & Now Electronic Charts Paper Charts

4. 1975-2011Then & Now X-Ray Film X-Ray Sensors

5. 1975-2011Then & Now Composite (RMGI) Restorations Amalgam Restorations

6. 1975-2011Then & Now Curing Light LED Light

7. 1975-2011Then & Now The Wand / STA - Single Tooth Anesthesia System Instrument Syringes

9. Table of Contents Set Up Basic operation Injection Techniques Maintenance Advanced options www.STAis4U.com

10. 1884 1904

11. Drug choice and Volume 4% Articaine HCL Adult: ½ cartridge Child: ¼ cartridge Preferred Vasoconstrictor Concentration 1:100,000 epinephrine 2% Lidocaine HCL Adult: ¾ cartridge Child: ½ cartridge Preferred vasoconstrictor concentration 1:100,000 epinephrine

12. What do you see ?

13. Agras, et al. 1979 Prevalence of Dental Fear? 20%

14. Technology ? 1853 1904 2010 150+ years

15. 1997 “New Innovation” Computer-Controlled Local Anesthetic Delivery System “C-CLAD”

16. Computer Controlled Local Anesthetic Delivery System 1997 – 1stGeneration 2007 – 3rd Generation

17. Disruptive Technology An innovation that alters a product or service in ways the market does not expect

18. Allows you to do something you can’t do any other way!

19. Simple mechanical system

21. Real-Time, continuous information

22. Visual and audible feedback

24. Hochman M, Chiarello D, Hochman C, Lopatkin R, Pergola S. Clinical Research Computerized local anesthesia vs. traditional syringe technique: Subjective pain response. NYS Dental Journal – 1997 Method & Material 50 patients (dentists) Palatal injection Each patient served as a control Subjects blinded to technique VAS scale, subjective pain scoring 3 examiners performed testing CCLADS: Fixed flow-rate = 0.005ml/sec = 2 minutes Handheld syringe: Maintained injection for 2 minutes

26. Wand group - 82% reported No Pain or Minimal Pain

28. Hochman, Friedman, Williams, Hochman Data on Different Tissue Types and Dental Injections Interstitial Tissue Pressure Associated With Dental Injections: A Clinical Study Quintessence Int 2006; Vol 37: 469-476. 200 dental injections (50/group) Group 1 – PDL Group 2 - Palatal injection Group 3 - Buccal infiltration Group 4 - Mandibular block Measured pressure in “real-time” Fixed flow-rate: 0.005ml/sec

29. Validation Prof. Stanley Malamed Prof. Bassett Prof. DiMarco Prof. Naughton Prof. J. Meechan Prof. Dionne

30. Lesson 1 Set Up and Basic Operation

31. Step - 1 FRONT Attach Foot Control Tighten Securely BACK Attach Power Cord Turn Power Switch On Wait 5 seconds for STA to Self-calibrate

32. Step - 2 ANESTHETIC CARTRIDGE Insert cartridge into holder Press firmly until spike punctures the diaphragm

33. Step - 3 Wand Handpiece & Needle Attach Luer-Lock needle to handpiece, if necessary Tighten securely Place needle and cap into holder on either side of STA

34. Step - 3 Shorten length of Wand Handpiece Remove tubing handpiece Shorten by “breaking” the length of the handle Mark the bevel

35. Step - 4 Insertion of Cartridge Holder Insert wings of holder into top of STA Turn counter-clockwise ¼ turn STA activates and purges handpiece of air Lights are activated

36. Step - 4b Removal of Cartridge Holder Push cartridge out using finger slots at top of cartridge holder Remove cartridge and continue Turn clockwise ¼ turn

37. Step - 5 Easy Learn: Training Mode The Training Mode provides an audible explanation of the various functions of the STA Allows one to become familiar with operating the STA Enable Training Mode by pressing and holding the “Hold to Train” button for 4 seconds

38. Step – 6 System is Ready

39. Learn the Injection of Your Choice Lesson 2:Performing the STA-Intra-ligamentary Injection Lesson 3:Performing the AMSA – (Palatal) Injection

40. Lesson 2 Tools needed to perform STA-IL Injection What you need to perform this injection: Bonded - 30-g ½ inch STA-Wand® Handpiece The STA drive-unit set to “STA” mode Activate Training Mode feature (optional)

41. Lesson 2 Performing STA-IL Injection What you need to learn: How to use Cruise-control feature Understand how DPS® works How to use STA aspiration to prevent back-spray of anesthetic into patients mouth

42. Performing STA-Intra-ligamentaryInjection

43. Easy Learn: Cruise Control Step - 1 What is the Cruise Control feature: The feature allows you to deliver anesthetic solution without the need of continuously depressing the foot pedal, it’s analogous to cruise-control in your car in which you release the accelerator and continue to drive. How do you activate: Start injection by depressing pedal After 3 seconds voice prompt will say “Cruise” Immediately release foot off pedal to remain in cruise mode How do you de-activate: Tap foot-control pedal to stop

44. Easy Learn: STA-IL Insertion Site Step - 2 Area effected: Single Tooth Anesthesia Injection site: Start on distal Bend needle, if necessary, to gain access It is best to maintain a direct view of the needle and it’s entrance to the sulcus at all times It is important for the shaft of the needle to be parallel with the surface of the root

45. You need a slight bend to the needle to allow proper access.

47. Incorrect Correct Unbent needle Bent needle (allows proper angle and access to PDL) NOTE: You cannot access the distal of the lower molars properly without bending the needle slightly.

50. Easy Learn: Dynamic Pressure Sensing Step - 4 What is the DPS feature: This feature provides real-time audible and visual feedback to indicate when the needle is properly positioned when performing the STA-Intra-ligamentary (PDL) injection. How to use: In STA-Mode only Start injection Insert needle into “assumed” correct PDL injection location Wait approximately 10-15 seconds in “assumed” correct location Listen & Watch, “ascending tone” & Increase of Pressure Scale through “orange” LED zone Maintaining the High “orange” or the “green” LED zone throughout confirms proper needle location

51. Easy Learn: DPS® technology Step - 5 Trouble Shooting: Problem: Pressure not building: Insufficient hand pressure on STA/Wand handpiece Did not wait 10 -15 seconds to allow pressure to build Incorrect needle position Over-Pressure Alert: Excessive hand pressure on STA/Wand handpiece Blocked needle tip with excessive hand pressure into PDL tissue Incorrect needle position

52. Lesson 3 Tools needed to perform AMSA - Injection What you need to perform this injection: 30-g ½ inch – Bonded STA-Wand® Handpiece Cotton-applicator with wooden-handle required The STA drive-unit set to “STA” mode

53. Lesson 3 How to Perform AMSA- Injection What you need to Learn: How to use Cruise-control feature How to perform Pre-Puncture Technique How to perform Anesthetic Pathway Technique How to use STA-aspiration to prevent back-spray of anesthetic into patients mouth

56. Clinical Technique: AMSA Injection

57. AMSA Injection A new technique that enables us to anesthetize a maxillary quadrant in the primary dentition with one injection.

58. Referances Friedman MJ, Hochman MN. The AMSA injection: A new concept for local anesthesia of maxillary teeth using a computer-controlled injection system. Quintessence Int. 1998; 29:297-303 Gibson RS, Allen K, Hutfless S, Beiraghi S. The Wand vs. traditional injection: A comparison of pain related behaviors. Pediatric Dent. 2000;22:458-462

59. Lesson 4 Performing P-ASA Injection What you need to Learn: How to use Cruise-control feature How to perform Pre-Puncture Technique How to perform Anesthetic Pathway Technique How to use STA-aspiration to prevent back-spray of anesthetic into patients mouth

60. Clinical Technique: P-ASA Injection

61. Easy Learn: P-ASA Insertion Site Step - 1 Area effected: The P-ASA can produce pulpal anesthesia of the Central and Lateral Incisors and the associated hard and soft palatal tissues Injection site: Entry point is the incisive groove surrounding the incisive papilla Final needle tip position is within the incisive canal

62. Easy Learn: Anesthetic Pathway Step - 2 What is the Pre-Puncture technique: The technique allows you to penetrate and advance the needle through the palatal gingiva with minimal discomfort to the patient How to perform: Place bevel against surface with cotton-applicator on-top Wait 8 seconds- then rotate and penetrate surface 1 - 2 mm Advancement Pace: 1 - 2 mm then wait 4 seconds to allow anesthetic to proceed needle Advance needle until bevel contacts surface of bone

63. Clinical Technique: P-ASA Injection

64. Lesson 5Tools needed to perform IA Block Injection What you need to perform this injection: Smaller Children: 30-g 1 inch – Bonded STA-Wand® Handpiece Adolescents : 27-g 1 ¼ inch – Bonded STA-Wand® Handpiece Normal Mode

65. Lesson 5Performing IA Block Injection What you need to Learn: How to change to Normal Mode How to use Cruise-control feature How to perform Anesthetic Pathway Technique How to use Bi-Rotational Insertion Technique How to use STA-aspiration How to use 2 speed operation

66. Easy Learn: Bi-rotation Insertion Bi-rotation Insertion technique: This technique allows you to minimize needle deflection during insertion. How to perform: Rotate needle in a back-n-forth fashion

67. Insertion Techniques RotationalInsertion Linear Insertion X X Deflection Linear Rotational

68. Easy Learn: 2-Speed Operation Step - 1 Using “Normal” mode 2-speed operation: You can more effectively and efficiently perform the IA Block using the 2-speeds How to use: Depressing the foot control lightly allows you to start the injection using the ControFlo (slower) flow rate – Use for the first ¼ cartridge of IA Block Depressing the foot control all the way down allows the second, more rapid rate to administer the remaining volume of anesthetic 1 2

69. Easy Learn: Aspiration Step - 2 Using Aspiration to prevent intravascular needle placement: You can prevent needle placement into a vessel by use of aspiration How to use: After completion of needle placement: Press and then release foot-control pedal to activate aspiration, which is six beeps for the complete cycle If you see blood in the needle hub, re-position needle and re-aspirate until negative observation 1 2 3

70. Easy Learn: Anesthetic Pathway Anesthetic Pathway technique: This technique allows you to penetrate and advance the needle through the mucosa and soft-tissues with minimal discomfort to the patient. How to perform: Penetrate mucosa Advancement Pace: 1- 2 mm then wait 4 seconds to allow anesthetic to proceed needle Advance needle until contact against surface of bone

72. Lesson 6Performing Multi-Cartridge Block

75. Effective

77. Lesson 7Performing Supraperiosteal/ Buccal Infiltration Injection What you need to Learn: How to change to Normal Mode How to use Cruise-control feature How to perform Anesthetic Pathway Technique How to use STA-aspiration How to use 2 speed operation

79. Easy Learn: Anesthetic Pathway Anesthetic Pathway technique: The technique allows you to penetrate and advance the needle through the mucosa and soft-tissues with minimal discomfort to the patient. How to perform: Penetrate mucosa Advancement Pace: 1 - 2 mm then wait 4 seconds to allow anesthetic to proceed needle Advance needle until contact against surface of bone

80. Lesson 8Maintenance What you need to Learn: How to change to Lubricate and Service Plunger How to clean and care for STA Drive Unit

81. Advanced Features What you need to Learn: How and Why to use Multi-cartridge feature How to change to Manual Plunger Operation How to change de-activate Aspiration How to adjust the Sound Volume control How to change Mode of operation

82. Advanced Lesson A - Anesthetic Level Indicator B - Auto Purge/Retract/Hold to Retract C - Multi-Cartridge/Hold to Train Mode D - Dynamic Pressure Indicator E - STA Mode F - Select Mode (Normal or Turbo) G - Aspiration Button H - Volume Control I - Power Light A C B D E F H G I

83. Multi-CartridgeUsed for 2nd or 3rd Cartridge on Same Patient While plunger is retracted, press Multi-Cartridge/Train Button Indicator light turns ON Remove empty cartridge; replace with new one Insert cartridge holder onto top of STA; continue injection STA defaults to Multi-Cartridge OFF after injection

84. Auto Purge / Manual Purge Auto Purge: default setting and will automatically purge air from the system when set up is complete Manual Purge: press the Auto Purge Button B then depress the foot pedal to purge air from the system B

85. Plunger Retraction Plunger Retracts Automatically: When Auto Purge/RetractLight(A) is ON When cartridge is emptied or when cartridge holder is removed Plunger Retracts Manually: Push and hold Retract Button(B) for4+ seconds A B

86. Aspiration If not needed, Aspiration can be turned OFF, by pressing Aspirate button After purging, STA defaults to Aspiration ON

87. Cartridge Volume LED lights indicate amount of anesthetic solution remaining STA “bongs” once when ¼ cartridge is expressed, twice when ½ is expressed, and three times when ¾ is used

88. Sound Volume Control To Change Audible Volume: Press up arrow to increasevolume Press down arrow to decrease volume

89. Modes of operation:STA, Normal, Turbo “Select” button change A- STA Mode– 1 speed ControlFlo only DPS® (Dynamic Pressure Sensing) B - Normal Mode– 2 speedControlFloand RapidFlo C- Turbo Mode- 3 speed ControlFlo, RapidFlo, and TurboFlo A B C

90. Foot Control and Mode Selections: Depress Pedal Slightly ControlFlo Speed Used for Palatal and PDL injectionsexclusively Start of all injections during the first ¼ cartridge Depress Pedal Moderately RapidFloSpeed Infiltration & Mandibular Block After first ¼ cartridge only Depress Pedal Firmly TurboFloSpeed After first ½ cartridge only

91. DPS® - Dynamic Pressure Sensing Informs the Dentist of Correct Injection Site (PDL Space) with Ascending Lights and Sounds Informs the Dentist if the Needle has Left the Correct Site Informs the Dentist if the Needle has been Blocked All Feedback Information in Real Time

92. STA-Intraligamentary Injection Technique: DPS - Dynamic Pressure Sensing Hold needle steadily in place with minimal pressure for approximately 15 seconds Ascending tones and lights will indicate the needle is in the correct injection site, the periodontal ligament space If ascending tones and lights are not initiated after 15 seconds, move needle slightly until the correct position is attained and lights and tones are seen and heard

93. THE ROLE OF ccladIN Pediatric dentistry

94. Behavioral Management CCLAD technology has improved the overall acceptance of the anesthetic injection in the pediatric population leading to less disruptive behavior.

95. References Lieberman, William H. Clinical Session: The Wand. Pediatric Dent. 1999;21:2 Allen KD, Kotil D, Larzelere RE, Hutfless S, Beiraghi S. Comparison of a computerized anesthesia device with a traditional syringe in preschool children. Pediatric Dent. 2002 Jul-Aug;24(4): 315-20

96. Pediatric Restorative Dentistry

97. Painless & Predictable

98. Bi-Lateral Restorative Dentistry Efficient

99. No Soft Tissue Numbness No Lip Biting

100. STA-IL Anterior Teeth

101. Bevel orientation

102. Mark the Bevel

103. Patient Compliance

104. Lack of Disruptive Behavior

105. Prevent “Dripping”

106. HAPPY PATIENTS

107. Cooperative Patients

109. 1” for older children mandibular blocks

110. ¾” for infiltration and blocks in younger children

112. Dr. Bill’s Helpful Tips Instrument location - LED’s should be clearly visible to operator & within reach Start instrument prior to injection to avoid startling the patient Use cruise control- NEVER turbo w/ pediatric patient

113. Dr. Bill’s Helpful Tips Avoid dripping the anesthetic in the mouth - the bitter taste is the easiest way to lose a compliant patient Develop a consistent pattern of injection site (distolingual is best due to anatomy if manageable)

115. 2 minute window to begin procedure

116. 20 minutes to complete treatmentWatch the videos on the website…very helpful! www.STAis4U.com Dr. Bill’s Helpful Tips

117. Timeliness

119. Painless- minimizes disruptive behavior

120. Immediate onset of anesthesia

121. no delay is important for a child’s short attention span

122. saves chair time

123. Multiple quadrants at the same visit

125. Our office mission statement includes “to create an atmosphere that allows the pediatric patient to succeed”. Nothing helps more than successful, painless anesthesia with no risk of collateral soft tissue damage from lip biting.